1. JEFFREY A. CARMEN, PH.D. PRIVATE PRACTICE MANLIUS, NY
BIOFEEDBACK IN THE TREATMENT OF FRONTAL LOBE DYSFUNCTION Child Psychiatry rounds 02/09/2018
JEFFREY A. CARMEN, PH.D.
PRIVATE PRACTICE
MANLIUS, NY

2. My office waiting room (wishful thinking)

3. CONTACT INFO (for office visit or copy of powerpoint or questions)

4. What is biofeedback?
It is just a fancy name for a tool for training the brain using Skinnerian and Pavlovian conditioning.
It includes:
Peripheral biofeedback (such as hand warming)
Brain biofeedback (also called neurofeedback)
EEG biofeedback (electron based neurofeedback)
HEG biofeedback (photon based neurofeedback)

5. ALL OF THE PREVIOUS DISTINCTIONS ARE ARTIFICIAL!!
All feedback using a physiological signal is biofeedback. The term neurofeedback is evoked to create the sense of increased precision, but in fact it is not more precise. However, the signals are messier.
It has a lot to do with semantics, status within the field, and marketing. To avoid confusion, I will be using the term biofeedback to describe everything.

6. Legal qualifications to do biofeedback.
Biofeedback is just a therapy tool, like lots of others. You need to have a license to practice in your chosen field such as Psychiatry, Psychology, Physical Therapy, Occupational Therapy. Certification is available. The only officially recognized certification body is:
BCIA
Ethically, you should obtain training in your chosen techniques (EMDR, insight therapy, biofeedback).

7. EEG biofeedback
EEG biofeedback (electron based brain biofeedback) is the most difficult to learn. Mostly because it is a very complicated signal and it is prone to electrical artifacts, such as electromagnetic interference and eye blink (eye roll) artifacts.
It is also done with minimal skin prep. Clinical EEG’s require careful skin prep. EEG biofeedback should also, but it is too time consuming to do in an office setting. The “solution” is an ultra high impedance amplifier that is more vulnerable to electronic interference.
Sometimes EEG biofeedback ends up being blink rate training (slower blink rate is more normal).

8. HEG biofeedback
HEG biofeedback (hemoencephalography) is photon based brain biofeedback. No skin prep required! Compared to EEG, it is a bit faster, immune to eye roll artifacts, and easily targets the prefrontal cortex. There are two kinds of HEG. nir HEG and pIR HEG. Neither are new, just not as well known as EEG biofeedback. Near Infrared (nir) HEG was invented by Hershel Toomin in (1916 – 2011) Passive Infrared (pIR) HEG was invented by me in It is what I used exclusively in my office, mostly because I focus on the prefrontal cortex.

9. Peripheral biofeedback
Peripheral biofeedback appears to directly train the autonomic nervous system, but does so via CNS regulation, so it is also neurofeedback (brain biofeedback). You are probably more familiar with this type. It includes, finger temperature training, muscle tension training, skin conductance, and general relaxation techniques. Peripheral biofeedback is a time honored tradition, that effectively treats various disorders based on mechanisms that are probably not correct. Example: migraines.

10. Relaxation training biofeedback
Early peripheral biofeedback was directed at training a relaxation response within the frame of reference of folks like Jacobson and Benson.
I used to do a lot of relaxation training. Now I don’t. In spite of seeming to be an innocent procedure, relaxation training can backfire because it also quiets the emotional management system. It removes the protective mechanism of tension.

11. So, what’s biofeedback good for?
Paroxysmal disorders such as migraines, seizures, rage responses, panic attacks.
General emotional management.
Other physiologically mediated (Raynaud’s).
Non medical focus such as ADHD, golf, stock market trading.

12. So, what’s biofeedback good for?
The common element is teaching control of physiological responses. Problems usually are not caused by frontal lobe dysfunction although they can be. However most can be managed by training the prefrontal cortex to be more dominant. It also improves peak performance.

13. HUMAN FRONTAL LOBES
The frontal lobes, especially the prefrontal region are a big deal! They account for a great deal of brain management.

14. HUMAN FRONTAL LOBES (they are also quirky)
This is the part of the brain that reflects the most recent evolutionary development. Because of that, it has the most “software bugs” (Hershel Toomim, 2009)
Because of its location, it is easily injured.
It is supposed to shut down easily during emergencies.

15. HUMAN FRONTAL LOBES Chopping off a chicken’s head.
Human frontal lobe is to the rest of the human brain as the chicken’s brain is to the rest of the chicken’s body.

16. 50,000 YEARS!!!
THE HUMAN BRAIN WAS DESIGNED FOR AN ENVIRONMENT THAT EXISTED 50,000 YEARS AGO
ADAPTATION TO MODERN LIFE IS ACCIDENTAL

17. Karl Pribram
02/25/1919 – 01/19/2015
Karl was one of the premier neurosurgeons in the US. He spent much of his early work defining the anatomical boundaries of the limbic system. He later altered his views on this in favor of a more external (holographic) perspective.
My dissertation was based on his EEG based theory of “mental effort”. My current work on training Prefrontal Cortical Dominance is also based on this theory of “mental effort”.

18. TYPICAL CLINICAL SYMPTOMS
Most dominant clinical symptoms can be viewed as a response that is a mismatch to the social environment.
Biofeedback is a way to retrain these response patterns.

19. ANXIETY
Anxiety is one of those emotions that tends to be incompatible with other emotions. It also tends to impair activity. It shuts down the prefrontal cortex.
Sexual arousal can shut down anxiety (and anxiety can shut down sexual arousal).
Assertive/aggressive behavior can shut down anxiety.
Most purposeful actions can shut down anxiety.
Activating the prefrontal cortex can shut down anxiety.

20. AGGRESSION Incompatible with anxiety
Rage is self reinforcing (it feels a lot better than anxiety, and there is a tension release when it is over).

21. DEPRESSION
As a brain mechanism it is a little bit unique and incompletely understood.
In terms of brain activity, depression localizes itself as low level of activity in the left prefrontal cortex in right handed left lateralized individual.
But what about folks who are reverse lateralized for language????

22. RECIPROCITY Planning and thinking inhibit emotions.
Emotions inhibit planning and thinking.
One goes up, the other goes down.

23. DSM-5 This is the “bible” for classification of mental conditions.
About 50% of the conditions listed represent the following:
EXCESSIVE RATE AND MAGNITUDE OF RESPONSE TO RELATIVELY BENIGN STIMULI
If you remember nothing else today, remember that.

24. SOME DISORDERS ASSOCIATED WITH EXCESSIVE RATE AND MAGNITUDE OF RESPONSE TO RELATIVELY BENIGN STIMULI
ADHD
MIGRAINE (and sometimes SEIZURE ACTIVITY)
ANGER (rage)
ANXIETY
DEPRESSION (maybe???)

25. PAROXYSMAL DISORDERS SUDDEN ONSET, SHORT DURATION, QUICKLY LEAVING “EVENTS” (rate and magnitude inhibited by frontal dominance)
MIGRAINE HEADACHES
SEIZURES
RAGE REACTIONS
PANIC ATTACKS

26. PAROXYSMAL DISORDERS SUDDEN ONSET, SHORT DURATION, QUICKLY LEAVING “EVENTS”
These disorders don’t necessarily have their origin in the front of the brain, but frontal inhibiting functions can make it difficult for them to initiate, and limit the rate and magnitude of the event.

27. Behaviors that fit the previous descriptions tend to occur in the presence of relatively reduced dominance of the inhibiting circuitry of the prefrontal cortex.
Note: Brodmann areas 9, 10, and 11 make up the pfc. This area is considered the executive control center and is largely inhibitory.

28. THE EVILS OF “POSITIVE FEEDBACK”
The human brain is design to work with powerful negative feedback loops in which the rate and magnitude of excessive activity is monitored and inhibited.
Lack of this inhibition allows “positive feedback”. For example, the howl of a microphone in an auditorium.

29. MY WORK INVOLVES INFRARED IMAGING OF THE PREFRONTAL CORTEX, AND THEN TRAINING FOR INCREASED PFC DOMINANCE USING pIR HEG.

30. Infrared Images measure radiated thermal energy in the 7 to 14 micron frequency spectrum
Infrared images have no color so the computer inserts “false color”
COLOR CODE
LOW ENERGY
HIGH ENERGY

31. Lamp captured in grayscale

32. Computer generated “false color”

33. INTERPRETATION GUIDELINES FOR PREFRONTAL CORTICAL INFRARED IMAGES
Generally, images with high variability in infrared activity (large range from low to high output) are found in people who have severe problems.
Low variability is associated with more normal functioning.
Progress is measured by reduced variability.

34. NORMAL INFRARED IMAGE (37yo female)

35. REFERENCE POINTS RIGHT TEMPORAL ARTERY LEFT ETHMOIDAL SINUS LEFT EYE
RIGHT EYEBROW
LEFT MAXILLARY SINUS
NOSE

36. Normal image
27 year old male

37. IMAGES OF DEPRESSION

38. 22yo male, periodic suicidal depression
22yo male, periodic suicidal depression. Did not tell me about it on intake. Baseline for first session.
DEPRESSION

39. End of first session. Feeling much better.
DEPRESSION

40. Baseline, second session, one week later.
DEPRESSION

41. End of second session, one week later.
DEPRESSION

42. Baseline, third session, two weeks later
Baseline, third session, two weeks later. Progressive lifting of depression.
DEPRESSION

43. End of third session. Progressive lifting of depression.

44. DEPRESSION points of interest
End of third session. Progressive lifting of depression.
DEPRESSION points of interest
FATIGUE
DEPRESSION MARKER, SMALLER DARK AREA OVER EYEBROW

45. 53yo female, depression, reverse laterlized for language.
Depression marker

46. 67yo female, MS, depression, reverse lateralized for language
Right side of her brain is dominant for language.
She “talks” with her left hand.

47. IMAGE VARIABLES
A dark area over the left eye can correlate with depression, delusions, or language problems.
If language lateralization is reversed, the meaning of the images is also reversed. For example, depression will be seen on the right side instead.

48. ANXIETY – CLINICAL IMPRESSIONS
Anxiety does not localize very specifically on infrared imaging, but the images are usually abnormal and typically show a low level of PFC activity. Also, it tends to be present with other emotions, which complicates diagnosis.

49. 17yo female, severe anxiety, occasionally rising to panic
17yo female, severe anxiety, occasionally rising to panic. Images from 6 sessions. Baseline image, first session.
ANXIETY

50. ANXIETY
17yo female, severe anxiety, occasionally rising to panic. End of first session.

51. 17yo female, severe anxiety, occasionally rising to panic
17yo female, severe anxiety, occasionally rising to panic. Baseline of second session one week later.
ANXIETY

52. 17yo female, severe anxiety, occasionally rising to panic
17yo female, severe anxiety, occasionally rising to panic. End of second session one week later.
ANXIETY

53. ANXIETY
17yo female, severe anxiety, occasionally rising to panic. baseline of third session.

54. ANXIETY
17yo female, severe anxiety, occasionally rising to panic. End of third session..

55. 17yo female, severe anxiety, occasionally rising to panic
17yo female, severe anxiety, occasionally rising to panic. Baseline of fourth session.
ANXIETY

56. ANXIETY
17yo female, severe anxiety, occasionally rising to panic. End of fourth session.

57. ANXIETY
17yo female, severe anxiety, occasionally rising to panic. Baseline for fifth session.

58. ANXIETY
17yo female, severe anxiety, occasionally rising to panic. End of fifth session.

59. 17yo female, severe anxiety, occasionally rising to panic..
She has stabilized nicely. Self reports are that both background anxiety and surges of anxiety are “softer and gentler”. At this point we will start to spread the appointments farther apart.
Note: the effect is from frontal inhibition rather than from relaxation. Inhibition is smoother and lasts longer.

60. Severe OCD, 20yo female (anxiety related disorder).
Note: OCD, anxiety, and depression often coexist.

61. Same girl after 6 months
Moderate improvement. OCD is very difficult. Usually returns somewhat when treatment stops.

62. AUTISM/ASPERGER SPECTRUM
Images generally localize to the non-language side of the forehead (usually over the right eye) and present as low level of activity (dark).

63. AUTISM SPECTRUM WITH ADHD
12yo male
Attentional problems
Social awareness and social insight deficits.
Problems with idioms.

64. AUTISM SPECTRUM WITH ADHD, end of session.

65. Clinical Comment: Behaviorally, autistic spectrum folk respond to pIR HEG in a binary fashion!

66. HEAD INJURIES
Head injuries consistently cause the prefrontal cortex to go offline.
Surprisingly, it is often relatively easy to bring it back online.
These folks also have a very limited ability to sustain mental effort. Often limited to 3 minutes.

67. HEAD INJURY (FRONTAL, 22yo male, cognitive deficits)
Hit tree head-on riding 4 wheeler with no helmet, 1 month coma. Language and thinking deficit.

68. Planned to go back to grad school, after 1 year of prefrontal cortical brain training. (Didn’t end up going.)
(This was one of the preceding “normal” images.)
SAME FELLOW, 1yr later

69. HEAD INJURY (ELECTROCUTED, 42yo male, dementia)
270 volt, hand to other body part
HEAD INJURY (ELECTROCUTED, 42yo male, dementia)

70. 51yo male, car accident, hit by 18 wheeler, headaches, depression, mental focus problems.

71. Same fellow, end of 10 frontal neurofeedback session, headaches better, but still problems.
Some improvement in overall symptoms.

72. ANGER / RAGE

73. 10yo male, rage episodes with limited or no memory for the event
10yo male, rage episodes with limited or no memory for the event. (Left lateralized for language.)

74. End of first session.

75. Baseline, second session.

76. Baseline, third session.

77. Baseline, fourth session. (He had a good week!)

78. ANGER, SEVERE ADD, POST CONCUSSION, (19yo female)

79. Same girl after one pIR HEG session ADD symptoms better but not gone.

80. Same girl on stimulant meds ADD symptoms normalized, still flares with anger.

81. “You guys are really pissing me off.”
Still on stimulants, “you guys are really pissing me off”
“You guys are really pissing me off.”

82. OTHER

83. CHRONIC ANXIETY, PARANOID DELUSIONS, 21yo male (IR IMAGE LOOKS SIMILAR TO DEPRESSION)
DIAGNOSIS: Paranoid Schizophrenia

84. MILD RETARDATION, Attention and language deficit, (20yo male).
ATTENTION PROBLEMS.
SHORT SPAN, RAPID SHIFTS OF ATTENTIONEVERY
2 TO 3 SECONDS
LANGUAGE
PROBLEMS, MOSTLY DYSPRAXIA ALONG WITH SOME DYSARTHRIA

85. Same fellow after “monthly tuneup”.
Speech clear, thoughts flow smoothly.
Same fellow after “monthly tuneup”.

86. IR Image Summary High variability is generally not a good sign.
Black areas are strongly suggestive of pathology.
Reduction of variability is strongly suggestive of improved functioning.

87. BIOFEEDBACK SUMMARY
Biofeedback “feeds back” a physiological signal for the purpose of training improved self regulation.

88. END